§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;
§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.
§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.
§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.
§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
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Observations:
Based on facility policy review, contact precaution review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for two of three residents reviewed on contact precautions (Residents 1 and 2).
Findings Include:
Review of facility policy, titled "Wound Care and Infection Control: General Policy" with a reviewed date of September 23, 2025, read, in part, "Purpose: Guide clinical staff providing care for resident wounds in processes necessary to prevent the spread of disease and infection. Clinical staff providing wound care adhere to foundational infection prevention guidelines during these processes. Hand hygiene is performed before wound procedure and gloves and gowns are donned. PPE (personal protective equipment) is removed and hand hygiene is performed directly after the procedure."
Review of Resident 1's clinical record revealed diagnoses that included pressure ulcer of left heel stage 4 (an injury to the skin and/or underlying tissue caused by prolonged pressure), pressure ulcer of sacral region stage 4, and tracheostomy status (a surgical opening created in the neck into the trachea to assist with breathing).
Review of Resident 1's comprehensive care plan revealed a focus area that read, in part, "Resident is at risk for infection, contact precautions: colonization" (presence and multiplication of microorganisms without causing disease, symptoms, or an immune response) with an intervention for "Please use PPE (gowns, gloves, and mask/goggles if splashes are anticipated) while in room, sanitize with alcohol based hand rub after care has been given and before leaving the room," initiated on August 29, 2025.
Observation outside of Resident 1 and 2's room on August 19, 2026, at 1:18 PM, revealed a sign that read, in part, "Contact Precautions everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit."
Observation of Employee 1 (Licensed Practical Nurse) on August 19, 2026, at 1:30 PM, revealed she entered Resident 1's room to perform a wound dressing change to his left heel. She did not don a gown or bring alcohol-based hand rub into the room.
Observation of Employee 1 on August 19, 2026, at 1:33 PM, revealed she changed her gloves and did not perform any hand hygiene in between glove changes.
Observation of Employee 1 on August 19, 2026, at 1:36 PM, revealed she changed her gloves and did not perform any hand hygiene in between glove changes
During an interview with Employee 1 on August 19, 2026, at 1:38 PM, the surveyor questioned if she knew to wear a gown when performing direct patient care and she replied "I forgot about that." The surveyor also revealed concern with the lack of hand hygiene between glove changes.
Observation of Employee 1 on August 19, 2026, at 1:39 PM, revealed she doffed her gloves into a biohazard bag and did not perform hand hygiene. Employee 1 then exited the room and went to biohazard closet and punched in the code to the door without performing hand hygiene.
During an interview with the Director of Nursing (DON) on August 19, 2026, at 1:58 PM, she revealed her expectation that staff would wear gowns when performing direct patient care for residents on contact precautions, and she would expect hand hygiene between glove changes, prior to exiting a room after care, and prior to touching other surfaces.
Review of Resident 2's clinical record revealed diagnoses that included dependence on respirator (ventilator) status (the inability to breathe independently and requires long-term mechanical ventilation), gastrostomy status (refers to the presence of an artificial opening in the stomach for feeding patients who cannot ingest food orally), and tracheostomy status.
Review of Resident 2's comprehensive care plan revealed a focus area that read, in part, "Resident is at risk for infection, contact precautions: colonization" with an intervention for "Please use PPE (gowns, gloves, and mask/goggles if splashes are anticipated) while in room, sanitize with alcohol based hand rub after care has been given and before leaving the room," initiated on December 31, 2025.
Observation of Employee 1 on August 19, 2026, at 1:18 PM, revealed she entered Resident 2's room to provide direct patient care for his tracheostomy and did not don a gown.
Observation of Employee 2 (Nurse Aide) on August 19, 2026, at 1:23 PM, revealed she entered Resident 2's room to provide direct patient care to answer his call bell and did not don a gown.
During an interview with the DON on August 19, 2026, at 1:58 PM, she revealed her expectation that staff would wear gowns when performing direct patient care for residents on contact precautions.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 09/30/2026
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
One, actions taken for situation identified:
1. Employee 1 & 2 were educated on donning proper PPE per type of isolation, proper hand hygiene and policy when entering a resident room and when performing direct care.
Two, how the facility will respond regarding residents in similar situations:
The facility recognizes that all residents have the potential to be affected. Please see sections three and four for system changes and monitoring mechanisms.
Three, system changes and measures that will be taken:
1. All Staff will be In-serviced on proper hand hygiene and proper PPE per isolation status.
Four, monitoring mechanism to assure compliance:
1. The Director of Nursing or her designee will conduct random audits 5 times per week for 1 month, then weekly for 1 month, and then monthly thereafter for compliance of proper PPE and Hand Hygiene during resident care for direct care of Residents.
2. The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
3. The NHA or his designee will conduct 5 audits per week for 1 month, then weekly for 1 month, then monthly thereafter for compliance of PPE before entering a room.
4. The NHA will report findings at Continuous Quality Improvement Committee Meetings
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